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Adult Screening and Immunization Documentation Form 20172018 Seasonal Influenza Vaccination Program Last Name:First Name: DOB:SSN: Mark answers by checking YES or NO for questions 14YESNO1. Are you
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Are you referring to the Sick or Disability Benefits form?
Employees who are unable to work due to illness or disability are required to file the Sick or Disability Benefits form.
You can fill out the Sick or Disability Benefits form online or by mail, providing details of your illness or disability and how it affects your ability to work.
The purpose of the Sick or Disability Benefits form is to provide financial assistance to employees who are unable to work due to illness or disability.
You must report details of your illness or disability, including diagnosis, treatment plan, and how it impacts your ability to work.
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